Background in Nursing
I obtained my bachelor’s degree in nursing six years ago. Following graduation and licensure, I was employed in a rehabilitation center. Most of the patients I cared for were post-stroke in need of therapy to achieve optimum functioning and the best quality of life possible. Thus, the care I provided consisted of secondary and tertiary prevention. After one year in the center, I was employed in the adult medical-surgical unit of a community hospital caring for patients with the same conditions as that in rehabilitation but in the acute phase of their illness. The hospital’s nursing service is Magnet recognized.
Personal Perspectives on Metaparadigms in Nursing
The metaparadigms of nursing represent the broad and unique areas of knowledge that enable nurses to provide care as professionals (Lee & Fawcett, 2013). These areas are patient, nursing, health, and environment. Knowledge and experience shaped my personal conceptions of these metaparadigms. To me, a patient is not just a person with physiologic needs but rather a whole entity with psychosocial, cultural, and spiritual needs as well. To enable the fulfillment of all these needs, a patient is not merely a recipient of care but an active participant (Doss, DePascal & Hadley, 2011). Hence, my concept of nursing is holistic and patient-centered. I believe that nursing is also ethical, evidence-based, effective, cost-efficient, high-quality, and satisfactory reflecting the accountability of nurses to the profession, patient, and organization.
Further, it is my view that health and illness are cultural and spiritual constructs, not just the absence or presence of disease. Therefore, it is necessary to strike a balance between patient beliefs and what the nurse believes is best. Hence, health is the outcome of partnership with the patient (Doss, DePascal & Hadley, 2011). Last, environment is not just the physical setting of care but also includes the social relationships and culture underlying the provision of care (Schalk et al., 2010). As such, the environment encompasses issues of the adequacy of resources, job satisfaction, staff commitment, management support, participative leadership, practice autonomy, and collegial relationships among others.
Practice-Specific Concepts and List of Propositions
Two concepts dominant in medical-surgical nursing practice that differentiates it from public or community health settings is acute care and acute care nursing. Acute care pertains to care rendered in situations of acute and complex illnesses, unstable chronic diseases, and critical conditions that are rapidly changing (NONPF, 2011). Such care is determined with the patient in consideration of available options and his or her preferences. As such, acute care nursing pertains to a nursing specialty requiring a special set of knowledge and skills in the management of actual and potential problems (AMSN, 2012). The goal of acute care nursing is to restore health as well as promote and maintain it.
Five propositions or assumption statements connecting the concepts together are the following:
1. Acute care in adult patients requires complex nursing care in a situation that is rapidly changing.
2. Adult patients with acute medical conditions require specialist nursing services.
3. Adult patients require nursing assessment and interventions for actual and potential health problems.
4. Acute care nursing addresses the restorative care needs of the adult patient as well as health promotion and maintenance.
5. Acute care nurses collaborate with patients in regard to decisions related to their care.
Defining and Employing Metaparadigms
My definition of the metaparadigms in nursing is shaped by knowledge and experience. The body of nursing knowledge on best practices, practice improvement, lived experiences of patients and nurses, strategies to resolve work environment issues, and nursing leadership and management validated by experience in a Magnet setting led me to conceptualize the metaparadigms in the manner described above. My views ultimately influence my behaviors in relation to patients and peers. For example, taking time to assess a patient not just for physiologic parameters but also emotional and spiritual needs results in holistic and satisfactory care and improved health outcomes.
Major Concepts in Practice and Related Philosophies or Theories
Caring, holism, nursing ethics, communication, cultural competence, critical thinking, and lifelong learning are some of the major concepts unique to professional nursing practice. Caring pertains to the use of self in acting for and on behalf of another in need of care in a manner that is intuitive, emphatic, honest, nonjudgmental, committed, and focused on the other (Linfield University, 2013). Holism, on the other hand, is a view of the person as a whole entity consisting of interrelated parts but whose sum is greater than the whole (Lusk & Fater, 2013). Watson’s theory of transpersonal caring is consistent with these concepts. The ten carative factors described in the theory include creating helping transpersonal connections for the purpose of gratifying patient needs while upholding their wholeness and dignity (George, 2011). It includes sensitivity to others, altruism, providing support and protection, and realigning the mind, body, and spirit.
On the other hand, nursing ethics is based on the discipline of bioethics founded on the ethical theories of deontology and utilitarianism (Kingori, 2013). Cultural competence is supported by Leininger’s transcultural nursing theory. Cultural competence is being knowledgeable of various cultures and the caring beliefs and practices of people (Maier-Lorentz, 2008). It is also being skillful in ascertaining the interrelationship between culture and care that permits the provision of congruent care. Meanwhile, Kataoka-Yoshira & Saylor (cited in Yildirim & Ozkahraman, 2011) developed a theoretical model identifying the five elements of critical thinking in nursing.
Faye Abdellah’s theory of the 21 nursing problems includes communication as one area indispensable to the functioning and growth of patients (George, 2011). Meanwhile, Imogene King’s goal attainment theory identified communication as necessary in sharing knowledge, information, judgments, and perceptions. Hildegard Peplau’s interpersonal nursing theory clarified that communication makes use of tools such as active listening, accepting, clarifying, interpreting, and teaching in the course of rendering patient services (Waugh et al., 2014). Last, lifelong learning was a theory that originated in the discipline of education (Xhignesse, 2003). In a Delphi study participated in by expert nurses, lifelong learning in nursing is gaining new perspectives through actively seeking learning opportunities as personal and professional, informal and formal (Davis, Taylor & Reyes, 2013). It is critically regarding one’s knowledge, skills, environment, and interactions through questioning and reflection.
Integration of Other Theories into Philosophy and Practice
Transcultural nursing is consistent with my philosophy of holistic and patient-centered care. Culture as a way of life is an integral part of the patient that makes him or her unique. Moreover, there are differences even among persons of the same culture. As such, it is important to assess each person’s culture to prevent stereotyping (Maier-Lorentz, 2008). Understand his or her cultural orientation in terms of one’s general understanding of that culture draws similarities and differences that broaden one’s knowledge. In practice, cultural assessment makes use of a tool inquiring into the patient’s expectations of their medical and nursing care, cultural practices that they want to incorporate in their care, and components of care that are contrary to their cultural beliefs and values. The result is a nursing care plan respecting and advocating for the patient’s culture-based preferences.
Nola Pender’s health promotion model highlights that health promotion behaviors are inspired by the desire to enhance well-being and achieve an optimum level of health. The author assumed that personal factors and experiences influence cognition and affect that, in turn, influence behavioral outcomes (George, 2011). It is consistent with holistic care as it considers the specific social and cognitive factors underlying patient commitment to health promotion or the lack thereof. Thus, the health promotion aspect of nursing care includes assessing for the patient’s knowledge, beliefs, perceptions, and feelings with regard to lifestyle change, medication adherence, smoking cessation, and other behaviors that promote health. In practice, referring the patient to the nurse educator for pre-discharge counseling and education, and subsequent referral to outpatient or community-based programs as needed are two nursing interventions.
Further, the skill acquisition theory by Patricia Benner relates to the professional progression of nurses from novice to expert. The nature of care provided depends on skill as determined by past experiences, the ability to perceive clinical situations as a whole, and the level of involvement in clinical situations (Kim & Choi, 2013). The concepts of life-long learning and critical thinking relate to the skill acquisition theory. Engaging in lifelong learning promotes constant reflection, and the ability to optimize the insights from each experience facilitates self-improvement. Lifelong learning further improves critical thinking skills through questioning, research, and self-reflection.
Kurt Lewis’ change theory suggests that change undergoes the stages of unfreezing the status quo, moving towards change, and refreezing change as the new norm (Manchester et al., 2014). The theory underscores the need to elicit buy-in, minimize resistance, and employ participatory change management. Last, role theory focuses on predicting an individual’s performance of a given role and the circumstances that bring about specific behaviors (Brookes et al., 2007).
A hospital-based pre-discharge health education program informed by the health promotion model was investigated through a quasi-experimental study that aimed to determine the efficacy in promoting individual responsibility for health, healthy nutrition, and interpersonal relationships (Eshah, 2013). The authors found that patients who participated in the program obtained higher scores in these areas of lifestyle reflecting successful lifestyle modification. In a survey of infection control competence among nurses, Kim & Choi (2013) found that skill levels can be categorized into Benner’s novice-to-expert continuum. Nurse (2014) describes the use of change theory in the successful implementation of change in pain management practices. A study of the Saudi nursing workforce consisting of only 36% natives showed how transcultural nursing guides the successful provision of culturally congruent care by the 64% who are foreign born and educated (Al Mutair et al., 2014). A study shows that mentoring is associated with lower levels of role ambiguity and conflict among nursing faculty members (Specht, 2013).
Role and Change Theories in Practice and the Organization
Change theory is integrated into my philosophy and practice in relation to communication. Open communication as an element of participatory change management employs active listening to elicit the input of stakeholders and allow them to take part in decision-making. In doing so, acceptability of change and commitment to it becomes more likely. In practice, I strive to collaborate with others in implementing change rather than imposing it. I also act as champion by exploring peer misconceptions about change and correcting them thereby improving the level of support for the change. With regard to role theory, past experiences of role conflict have taught me that it is not enough to complain about it and it is unproductive to be passive and do nothing. The work environment has a significant influence on the performance of nurses and for this reason, it is important for me initiate discussions about role conflicts commonly experienced and advocate for change in the workplace in the future.
Change theory and role theory are applicable at the level of the organization as well. A top-down approach to change implementation is likely to be met with resistance contributing to the failure of the change project. People adopt new behaviors if they believe in the benefits of doing so and are committed. Permitting them to have a say in change promotes common ownership of the project that is key to buy-in (Manchester et al., 2014). In addition, nurse managers must recognize the negative impact of role conflict and role ambiguity on job satisfaction, commitment to the organization, and quality of nursing care. Issues pertaining to the nursing role warrant interventions to achieve resolution.
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